Make A
DTP,Dividend Payout to Re-investment or Growth
Transaction

Folio Number

Investor Name

Broker Details

Broker Code

Sub Broker ARN Code

Sub Broker Code (As alloted by ARN)

EUIN

I/We hereby confirm that the EUIN box has been intentionally left blank by me/us
as this is an ‘execution-only’ transaction without any interaction or advice by
the employee/relationship manager/sales person of the above distributor or notwithstanding
the advice of in-appropriateness, if any, provided by the employee/relationship
manager/sales person of the distributor and the distributor has not charged any
advisory fees on this transaction.

Requester Name

By mentioning ARN/RIA code, I/we authorize you to share with the Distributor/Investment Adviser the details of my/our transaction(s) in the scheme(s) of ICICI Prudential Mutual Fund.